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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to co ristruct and/or instaii the work herein described. This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. a Job Address E 1)� ,71 S Cit es"� / J� y Lot Size a PM Owner's NameAddress v I� _ Phone !� Contractor �``CC�` .u.�✓l Address Z197' '' E -i `-' License No. 7�Zz6C> Phone r!Tar TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS O Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation pia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications (l Public �7 j P)(Other I-1 Delta Depth of Grout Seal �Type of Grout I I Irrigation !� .Approx. Depth l I Eastern Surface Seal Installed by a Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction W.I et rl EeJi)top50') -- l�0p Fil low 501 TYPE OF SEPTIC WO K: NEW ALLATiON I 1 REPAIR/ADDITIO l 1 DESTRUCTION l 1 (No septic system permitted if public sewer is gpit mai have expired withou available within 200 feet.) Installation will serve: a yce_ Comym rc 1 O r Number of living units.ww L1amgecarat `� "r I P'�- -- 6 Character of soil to a rb demy trt, )X '., t Water table depth �JYl b. . SEPTIC TANK Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE LI No. & Length of litres Total length/size b FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant^t call for all required inspections. Complete drawing on reverse side. A f Signed XTitle:_ ` 4 Date: F/O��j�D�EPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 12 Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNTDUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. r EH 13-2+(REV.1 5) r EVI 14,28 `''{� !Z 0